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Internal Medicine

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A woman in her 60s with a history of diabetes mellitus, hypertension, and hypothyroidism presented to the emergency department after being found confused, non-verbal, and with low urine output in a nursing home. Her last known well was around 6 a.m. before presentation. Her temperature was 94.5°F, blood pressure (BP) was 179/80 mm Hg, heart rate (HR) was 50/min, and saturation was 97% on room air. She was cold to touch. The lungs were clear to auscultation bilaterally. She was noted to have gaze preference initially to the right, then to the left, right-sided weakness, and left facial droop. A code stroke was activated; however, the CT head showed no acute pathology. Laboratory results were significant for white cell count of 12,500 cells/mm3, and a PH of 7.35. An hour later, her BP dropped to 88/50 mm Hg and HR was 42/min with no rectal temperature measurement detected despite multiple attempts. The patient was started on intravenous fluids (IVF). Her ECG on presentation and an hour later are shown in Figure 1A, B. (Already shared)

What's the diagnosis and what would you do next?


 A. Urgent transcutaneous pacemaker placement 

B. Emergent percutaneous coronary intervention

C. Active rapid rewarming 

D. Active slow rewarming 

E. Urgent hemodialysis

I K
Mazen Kherallah
N G

https://pubmed.ncbi.nlm.nih.gov/32408343/

The above study is in patients with hypothermia associated with circulatory arrest preferring slow over fast.

And this study in rats showed that hypothermia followed by rapid rewarming increased Longa score and neurological deficit score

https://www.sciencedirect.com/science/article/abs/pii/S0006291X16306003

And this study apply to our patient above and confirms that Slow, controlled rewarming is feasible and may be used for ICP and CPP control after moderate hypothermia for space-occupying infarction but no comparison with fast rewarming.

https://www.ahajournals.org/doi/10.1161/hs1201.99511

Please @Everyone share if you have other studies

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